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Table 32-6 Parasitic causes of central nervous system lesions
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Cestodes (tapeworms) Cysticercosis (T solium) and coenuriasis (T multiceps) Sparganosis (Spirometra) Hydatid disease (Echinococcus) Nematodes (roundworms) Trichinosis Angiostrongyloidiasis (A cantonensis) Gnathostomiasis (G spinigerum) Baylisascariasis (B procyonis) Strongyloidiasis (S stercoralis) Visceral larva migrans (Toxocara canis, T cati) Trematodes ( ukes) Schistosomiasis (S japonicum, S mansoni, S hematobium) Paragonimiasis Other tropical and parasitic infections Toxoplasmosis (T gondii) Amebiasis Entamoeba histolytica, Naegleria fowleri, Balamuthia mandrallis Tuberculoma (M tuberculosis and atypical forms)
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Seizures with mature lesions, hydrocephalus, ventricular and multiple subarachnoid implantation Subcutaneous nodule, seizures Focal cerebral ndings, raised ICP Skin lesions, severe myositis, brain lesions, eosinophilia, meningitis, encephalitis (rare) Meningoencephalitis, eosinophilia Eosinophilic meningoencephalitis Eosinophilic meningoencephalitis (from racoon bites) Encephalitis, myelitis, seizures Eosinophilic meningoencephalitis
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Cyst with scolex; late calci cation
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Migrating granuloma or mass Large uid- lled cyst, solid chitinoma Granuloma Granuloma, nodule, migrating track
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Irregular nodular enhancing lesions, may change position
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Myelopathy, seizures, tumor symptoms, swimmer s itch Seizures, meningoencephalitis, pulmonary lesions Seizures, focal cerebral ndings Colitis, liver abscess, rare brain abscess Primary amebic meningoencephalitis, seizures (after swimming) Granulomatous encephalitis Seizure
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Single granuloma, may be large Single granuloma
Single or multiple enhancing lesions Abscess or encephalopathy Multiple small abscess lesions
encephalitis (the liform larvae may be seen in cerebral capillaries and in cerebral parenchyma) and emboli from mural thrombi arising in infected heart muscle Treatment In the treatment of trichinosis, thiabendazole, an antihelminthic agent, and corticosteroids are of particular value Thiabendazole, 25 mg/kg twice daily for 5 to 7 days, is effective in both the enteral and parenteral phases of the disease This drug prevents larval reproduction and is therefore useful in patients known to have ingested trichinous meat It also interferes with the metabolism of muscle-dwelling larvae Fever, myalgia, and eosinophilia respond well to the anti-in ammatory and immunosuppressant effects of prednisone (40 to 60 mg daily), and a salutary effect has been noted on the cardiac and neurologic complications as well Other nematodes, mainly toxocara (the cause of visceral larva migrans), strongyloides, and angiostrongyloides may rarely migrate to the brain, but each is characterized by a systemic illness, which is far more common than the neurologic one Parasitic meningitis is discussed below
Diseases Due to Cestodes (Table 32-6)
Cysticercosis This is the larval or intermediate stage of infection with the pork tapeworm Taenia solium In Central and South America and in parts of Africa and the Middle East, cysticercosis
is a leading cause of epilepsy and other neurologic disturbances Because of a considerable emigration from these endemic areas, patients with cysticercosis are now being seen with some regularity in countries where the disease had previously been unknown Usually the diagnosis can be made by the presence of multiple calci ed lesions in the thigh, leg, and shoulder muscles and in the cerebrum The cerebral manifestations of cysticercosis are diverse, related to the encystment and subsequent calci cation of the larvae in the cerebral parenchyma, subarachnoid space, and ventricles (Fig 32-8) The lesions are most often multiple but may be solitary Before the cyst degenerates and eventually calci es, CT scanning and MRI may actually visualize the scolex Most often the neurologic disease presents with seizures, although many patients are entirely asymptomatic, the cysts being discovered radiologically It is only when the cyst degenerates, many months or years after the initial infestation, that an in ammatory and granulomatous reaction is elicited and focal symptoms arise In some patients, a large subarachnoid or intraventricular cyst may obstruct the ow of CSF, in which case the surgical removal of the cyst or a shunt procedure becomes necessary Proano and colleagues, however, have reported on a series of such cases with cysts larger than 5 cm in diameter, which they have treated medically In a more malignant form of the disease, the cysticerci are located in the basilar subarachnoid space, where they induce an
brain, leaving a visible track as it moves Subcutaneous nodules are the most common lesions This parasite is found predominantly in the Far East The nervous system may also be invaded directly by certain worms (Ascaris, Filaria) and ukes (Schistosoma, Paragonimus) These diseases are virtually nonexistent in the United States except among those who have recently returned from endemic areas Schistosomiasis, however, is of such great importance and often invades the nervous system in such characteristic ways that it is considered below in detail
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